I knew what would benefit the patient, and the doctor Mallison was sitting right next to me, yet I said nothing. I knew I had a 50/50 chance this doctor was going to say something like, "Rick, we are not going to extubate this patient!"
Better yet, the other day Dr. Peterson was sitting at the desk charting, and Dr. Mallison came up to him and said, "Why didn't you order ventilator protocol! You need to order ventilator protocol! I see there was no sputum sample either. If you would have ordered the protocol this wouldn't have happened!"
Dr. Mallison walked out of the room. That was when Dr. Peterson spoke for the first time, "What does she think she is: the chart police. There's no law that says I have to order the ventilator protocol."
Dr. Mallison is like a ticking time bomb. She has absolutely no empathy for the fact that you are at the bedside and might know what's going on with the patient at that moment either.
One time I had a patient who's sats were in the 70s and increased the oxygen to a 50% ventimask, and then I called the doctor. My thinking was that if I didn't take this action in this order, the patient would be dead by the time the doctor answered her page.
It's common sense. Right?
Yet Dr. Mallison laid into me: "Why do you raise oxygen without an order. What if she was a retainer? You should know better than to raise oxygen without an order!"
So you can see, she's a hard liner. So here I was, sitting next to her with my ideas for helping the patient, yet I was afraid to ask her.
Later that night the nurse had a concern and wanted to call the doctor. Normally she would have picked up the phone and called, yet she turned to me and said, "I don't want to talk to her. She'll say something like, "Why are you calling me at 2 in the morning."
Callousness is a trait that no doctor should have. To have no empathy and show no respect for other doctors, nurses and respiratory therapists only results in worse patient care.
Showing posts with label DR wisdom. Show all posts
Showing posts with label DR wisdom. Show all posts
Saturday, January 29, 2011
Friday, January 7, 2011
Is your doctor out of date?
"Is your doctor out of date?" That's a valiant question, and the title of a Reader's Digest article from the November, 2009, issue.
Of interest to learn is that while asthma used to be treated as an acute disease, whereas doctors would wait until an asthmatic had an attack and treated the symptoms, asthma experts now recommend using asthma controller medicines, preferably inhaled corticosteroids, to PREVENT asthma.
Yet, evidence shows that only 50% of the 9 million asthmatic kids are currently on inhaled corticosteroids, either because their doctors didn't prescribe them, or they weren't told to continue to use them when they were feeling well.
The old way of treating high blood pressure was to tell people to eat better and live better, although the new method is to make sure any person who has a blood pressure higher than 140/90 you need to be on one or more blood pressure medicine to bring it down to normal.
Past evidence showed that less than 10% of those with high blood pressure made the necessary changes to lower their blood pressure, which is why the "guidelines" for treating high blood pressure were changed.
It used to be that for those with back pain, an x-ray was taken, perhaps an MRI, and sometimes even invasive surgery was performed. Yet, evidence shows none of those ever did any good, and often resulted in unnecessary and painful procedures that did more harm than good.
New guidelines focus on encouraging exercise and heat pads to overcome the pain, and only going the next step if there is severe weakness, a history of cancer, or problems urinating.
While evidence show clot busting medicines like Asprin, angioplasty and other "proven steps" have been proven to make a big difference in outcomes of those having a heart attack, evidence shows fewer than 50% were getting clot busters, and 25% referred for other treatment.
Since then efforts have been made to get the word out.
All humans are creatures of habit, which makes all of us, in a way, set in our ways. This is why experts have come up with guidelines that are updated, and have made efforts to continually educated not just doctors, but patients and family members to.
As noted by the article, "when your doctor suggests a treatment, you should hear the word evidence in his or her explanation."
Yet, still, a guideline is still a guideline. There are times when common sense should prevail. A good example is the asthma guidelines, which state if you use your rescue medicine more often than 2-3 times in a week your asthma is not controlled.
But sometimes you have a hardluck asthmatic who does all the right things, yet still has trouble with his asthma. In this case, the asthmatic may have good control and still require to use his rescue medicine a few times a day.
So, is your doctor out of date? He might be, and therefore it's your job to know, to do your research, and to nudge him or her in the right direction if he or she is.
Click here to know if your doctor is doing a good job.
Click here to learn about maintaining a good relationship with your doctor
Of interest to learn is that while asthma used to be treated as an acute disease, whereas doctors would wait until an asthmatic had an attack and treated the symptoms, asthma experts now recommend using asthma controller medicines, preferably inhaled corticosteroids, to PREVENT asthma.
Yet, evidence shows that only 50% of the 9 million asthmatic kids are currently on inhaled corticosteroids, either because their doctors didn't prescribe them, or they weren't told to continue to use them when they were feeling well.
The old way of treating high blood pressure was to tell people to eat better and live better, although the new method is to make sure any person who has a blood pressure higher than 140/90 you need to be on one or more blood pressure medicine to bring it down to normal.
Past evidence showed that less than 10% of those with high blood pressure made the necessary changes to lower their blood pressure, which is why the "guidelines" for treating high blood pressure were changed.
It used to be that for those with back pain, an x-ray was taken, perhaps an MRI, and sometimes even invasive surgery was performed. Yet, evidence shows none of those ever did any good, and often resulted in unnecessary and painful procedures that did more harm than good.
New guidelines focus on encouraging exercise and heat pads to overcome the pain, and only going the next step if there is severe weakness, a history of cancer, or problems urinating.
While evidence show clot busting medicines like Asprin, angioplasty and other "proven steps" have been proven to make a big difference in outcomes of those having a heart attack, evidence shows fewer than 50% were getting clot busters, and 25% referred for other treatment.
Since then efforts have been made to get the word out.
All humans are creatures of habit, which makes all of us, in a way, set in our ways. This is why experts have come up with guidelines that are updated, and have made efforts to continually educated not just doctors, but patients and family members to.
As noted by the article, "when your doctor suggests a treatment, you should hear the word evidence in his or her explanation."
Yet, still, a guideline is still a guideline. There are times when common sense should prevail. A good example is the asthma guidelines, which state if you use your rescue medicine more often than 2-3 times in a week your asthma is not controlled.
But sometimes you have a hardluck asthmatic who does all the right things, yet still has trouble with his asthma. In this case, the asthmatic may have good control and still require to use his rescue medicine a few times a day.
So, is your doctor out of date? He might be, and therefore it's your job to know, to do your research, and to nudge him or her in the right direction if he or she is.
Click here to know if your doctor is doing a good job.
Click here to learn about maintaining a good relationship with your doctor
Saturday, April 17, 2010
The natural order of mistakes
When a patient goes into respiratory failure, or cardiac failure, or both, this presents a stressful moment for the medical workers taking care of the patient. Basically, if nothing was done the patient would die, and therefore without our intervention the patient would die.
This provides many of us with an adrenaline rush. During these stressful moments even the best trained mind can fail to work adequately. I've seen the best of the best RTs bag with the mask upside down. I saw a doctor forget to order Epinephrine. I've seen nurses who never miss IVs miss up and down the arm, with blood spattering everywhere. I've seen nurses and lab technicians get overanxious and forget to cap a contaminated needle, and poke someone with it. I've seen an RT set up a vent and yet forget to turn it on. I've seen the medical workers so focused on what to do next that I had to yell, "Um, someone better get on the chest and do CPR!"
Once I was bagging the same time I was holding the mask over a patients face, and the patient was getting good chest movement. The doctor decided to take the mask from me and she squeezed the mask so tight over the patient's face he wasn't able to get any air in. I tried to explain this to the doctor, but he said, "This is what they say to do in ACLS!" Well, ACLS also recommends common sense and constructive intervention. Thankfully that doctor who was obviously acting on adrenaline found something else to do.
You see, we prepare for this all the time, and yet when it comes you have to realize we are only humans. Some of the time our experience and education saves the life of the patient, and other times the patient does not make it. Still, there are many times that no matter what we did the patient would have died.
Yes, it is true, there are moments in the emergency room, especially when the patient is someone you know, or a kid, where the tension is so high you can feel it as something palpable in the air we breath in. You can smell it. You can even hear it. Yet, still, we are trained over and over again as to do what we do, so during these tense moments our bodies naturally do what is right.
Still, we are, after all, humans. And that is why after watching someone do something stupid, I usually take it with a grain of salt. Usually something stupid was something so minor it made no difference to the outcome of the patient whatsoever. For instance, recently I assisted with an intubation, and it took me 10 seconds instead of the two seconds the doctor expected to inflate the cuff on the ETT following the intubation. What I did had absolutely no impact whatsoever on the patient outcome. Yet, Instead of being understanding and appropriate, the doctor was condescending and inappropriate.
I was called stat to OB to be on standby for a 34 week gestation baby. As soon as I arrived in the delivery room the baby was delivered by the nurse. It appeared to me the nurse did everything appropriate, yet later, after the doctor arrived, the nurse was scolded. He said, referring to her delivering the baby, "That was a rookie mistake that will never be repeated again." I saw the whole thing. If she had not delivered the baby, it would have probably flopped on the floor.
One thing that I learned by the first RT to orientate me before I worked at Shoreline was that every other person at a code, or at the birth of a bad baby, will be stressed and the adrenaline will be flowing. She said that if any person is calm and level headed it should be you the RT. Make sure you know your stuff right side up and upside down, and know as much about what the nurse should be doing too so you can offer level headed advice and suggestions during the process. "As we are, in fact, a team. Our jobs are to help each other out. What you forget, it's my job to remember. What I forget, it's your job to remind me."
Yet, while most doctors, nurses and RTs are understanding of this rule, some continue to be inappropriate and condescending. They expect everything to be run as perfect. The truth is, I have never in my life left a code and said, "Well, that one went great." I am always saying to myself, "What could I have done better."
I had a discussion regarding this recently with four nurses. I said, "Do you think I think too much. Should I just assume I did my best, the nurse did her best, and so too did the doctor?"
We all came to the conclusion that we all second guess ourselves. It's natural. We also decided that the medical worker who doesn't second guess himself is the one we should be worrying about. The condescending doctor, the arrogant nurse, the omniscient RT are the one's who are the problem.
We must never forget we are a team. We work together for the benefit of the patient. We are all humans prone to doing stupid things, or making mistakes. It's our job to help the other members of the team do their jobs right when a natural brain infarct occurs.
Likewise, if a mistake is made, it should be addressed appropriately.
Here's a good analogy. Brandon Inge swiftly swoops up the ball and, instead of setting his feet and making a good throw, he tosses it over the head of the first baseman. Jim Leyland doesn't say anything, because he knows Brandon knows what he did wrong. Yet, Leyland decides, if he does it again, then he didn't learn and I'll have to address it.
That's the way things go in baseball. It's common sense. And it's also the way things go in life. Yet, some condescending people don't care about the natural order of things. Empathy lacking, you did wrong and therefore you need to be treated as a kid.
This provides many of us with an adrenaline rush. During these stressful moments even the best trained mind can fail to work adequately. I've seen the best of the best RTs bag with the mask upside down. I saw a doctor forget to order Epinephrine. I've seen nurses who never miss IVs miss up and down the arm, with blood spattering everywhere. I've seen nurses and lab technicians get overanxious and forget to cap a contaminated needle, and poke someone with it. I've seen an RT set up a vent and yet forget to turn it on. I've seen the medical workers so focused on what to do next that I had to yell, "Um, someone better get on the chest and do CPR!"
Once I was bagging the same time I was holding the mask over a patients face, and the patient was getting good chest movement. The doctor decided to take the mask from me and she squeezed the mask so tight over the patient's face he wasn't able to get any air in. I tried to explain this to the doctor, but he said, "This is what they say to do in ACLS!" Well, ACLS also recommends common sense and constructive intervention. Thankfully that doctor who was obviously acting on adrenaline found something else to do.
You see, we prepare for this all the time, and yet when it comes you have to realize we are only humans. Some of the time our experience and education saves the life of the patient, and other times the patient does not make it. Still, there are many times that no matter what we did the patient would have died.
Yes, it is true, there are moments in the emergency room, especially when the patient is someone you know, or a kid, where the tension is so high you can feel it as something palpable in the air we breath in. You can smell it. You can even hear it. Yet, still, we are trained over and over again as to do what we do, so during these tense moments our bodies naturally do what is right.
Still, we are, after all, humans. And that is why after watching someone do something stupid, I usually take it with a grain of salt. Usually something stupid was something so minor it made no difference to the outcome of the patient whatsoever. For instance, recently I assisted with an intubation, and it took me 10 seconds instead of the two seconds the doctor expected to inflate the cuff on the ETT following the intubation. What I did had absolutely no impact whatsoever on the patient outcome. Yet, Instead of being understanding and appropriate, the doctor was condescending and inappropriate.
I was called stat to OB to be on standby for a 34 week gestation baby. As soon as I arrived in the delivery room the baby was delivered by the nurse. It appeared to me the nurse did everything appropriate, yet later, after the doctor arrived, the nurse was scolded. He said, referring to her delivering the baby, "That was a rookie mistake that will never be repeated again." I saw the whole thing. If she had not delivered the baby, it would have probably flopped on the floor.
One thing that I learned by the first RT to orientate me before I worked at Shoreline was that every other person at a code, or at the birth of a bad baby, will be stressed and the adrenaline will be flowing. She said that if any person is calm and level headed it should be you the RT. Make sure you know your stuff right side up and upside down, and know as much about what the nurse should be doing too so you can offer level headed advice and suggestions during the process. "As we are, in fact, a team. Our jobs are to help each other out. What you forget, it's my job to remember. What I forget, it's your job to remind me."
Yet, while most doctors, nurses and RTs are understanding of this rule, some continue to be inappropriate and condescending. They expect everything to be run as perfect. The truth is, I have never in my life left a code and said, "Well, that one went great." I am always saying to myself, "What could I have done better."
I had a discussion regarding this recently with four nurses. I said, "Do you think I think too much. Should I just assume I did my best, the nurse did her best, and so too did the doctor?"
We all came to the conclusion that we all second guess ourselves. It's natural. We also decided that the medical worker who doesn't second guess himself is the one we should be worrying about. The condescending doctor, the arrogant nurse, the omniscient RT are the one's who are the problem.
We must never forget we are a team. We work together for the benefit of the patient. We are all humans prone to doing stupid things, or making mistakes. It's our job to help the other members of the team do their jobs right when a natural brain infarct occurs.
Likewise, if a mistake is made, it should be addressed appropriately.
Here's a good analogy. Brandon Inge swiftly swoops up the ball and, instead of setting his feet and making a good throw, he tosses it over the head of the first baseman. Jim Leyland doesn't say anything, because he knows Brandon knows what he did wrong. Yet, Leyland decides, if he does it again, then he didn't learn and I'll have to address it.
That's the way things go in baseball. It's common sense. And it's also the way things go in life. Yet, some condescending people don't care about the natural order of things. Empathy lacking, you did wrong and therefore you need to be treated as a kid.
Saturday, January 23, 2010
Dear Doctors: Albuterol is not an expectorant
I dare you to post this on your bulleton board!!!
Note to doctors:
I just want you to know that Albuterol is a bronchodilator and not an expectorant. It will not help a patient who is breathing normal produce a gob of sputum and cough it up.
If you order for me to do a treatment for a sputum induction, and I go into the room and the patient has good lung sounds and is breathing normal, all I'm going to do is give the breathing treatment and hand the patient a sputum cup.In fact, in the past when your brethren have asked me to give a treatment for a sputum I have been known to say, "I'll give him a cup."
I have no idea where you guys got the idea that Albuterol is an expectorant or a cough inducer (well actually I do), but you are wrong. It does not produce sputum. Normal healthy lungs are not going to produce sputum even with a bronchodilator.
Nuff said. Thanks for listening. I hope you hear me too.
Sincerely, your humble respiratory therapist
I dare you!
Friday, December 11, 2009
It seems bronchodilator fallacies trump scientific facts
So why do we have science if nobody is going to use it? Why do we have truth when it's easier to believe a fallacy? Why? Why? Why?
Am I the only one to ask questions like this? I doubt it, although I don't think there are many of us.
I have two examples to what I'm questioning here: global warming and bronchodilator usage.
We've been studying weather patters for over 100 years not. If you put that into consideration, that's 100 years in something like 100+ billion years. If you do the math, I bet that's a shorter amount of time that 0.00000000000001% of our history. Yet, based on the numbers we have accumulated, people have come to a conclusion.
I find this funny, because most scientists (as you can see by this post) are still questioning the science. Not even scientists can come to a logical conclusion regarding global warming. Yet you have a majority of politicians willing change our economic landscape based on this theory, and a majority of the world population willing to buy into it.
To be honest here, I am neither a believer nor a disbeliever in the theory of global warming. I think it's best to let science decide. It's best to look at the trends which show constant periods of warming, followed by periods of cooling, and so forth.
Yet some people fail to look at this big picture, and they make political opinions based on the current trend. For example, in the 1970s the trend was toward global cooling, and you had scientists actually proposing melting the polar ice caps to warm the planet. Aren't we glad that never happened?
From the late 1970s to about 1998 the trend trended upward, and you had the global warming scare which is ongoning, despite stagnant global temps since 2000.
You have people like the honorable Al Gore claiming that if we don't clean up our planet it won't exist in 10 years. To me, this is a scare to get people to send more money his way. It's all about money. It's all about selling a political view over science.
Personally, I think it's a good idea to be environmentally conscious. I think it's a good idea to reduce, reuse and recycle. I think it's a good idea to look for alternative energy sources. Yet let's not get drastic and force one view based on a theory.
The same can be said of bronchodilators like Ventolin. You have doctors and nurses believing that Ventolin is needed every time they hear a wheeze or see a short of breath patient. Yet the science proves otherwise.
Still, when you go to correct a nurse or a doctor, when you share the facts and the science about bronchodilators, they say that I am being lazy. A great example of this occurred last night when I was called to do a breathing treatment for a person who was dyspneic due to pneumonia.
I approached the nurse and said, "You know Ventolin does nothing for pneumonia."
She said, "Yes it does. It opens the airways and helps the patient cough up the pneumonia."
"That's a fallacy," I said. "Science has proven that Ventolin is a bronchodilator you are right. But pneumonia does not cause bronchoconstriction, so the air passages in that person's lungs are already dilated. Thus, a bronchodilator will not expand these air passages beyond what they already are. In fact, there is no need to because pneumonia is not in the bronchioles. There are no secretions trapped in the bronchioles."
"Where did you hear that from?" the nurse said angrily.
"Not only that," I said, continuing on with the facts I've learned through my many years of research, "Pneumonia is a disease of inflammation of the alveoli. Bronchodilators don't treat inflammation, that's the job of corticosteroids and perhaps even antibiotics to kill the bacteria down there if it's bacterial, which it usually is.
"Likewise, I added," her face was red as a beat by now, "Ventolin is 0.5 microns, just the perfect size to fit into the air passages to get to the beta one receptors there. The Alveoli are 0.1-0.2 microns wide, so Ventolin doesn't even get down there.
"And to top that off," I said patting the side of the nurses station in my confident rage, "I don't even believe there are beta adrenergic receptors in the alveioli."
"You're just trying to get out of work," she said. She smiled. She's a great person, although she needed the education regardless that it was going to sink in or not.
By this time Dr. Q1 is standing right next to her, and she interjected: "Jill is right. Ventolin relaxes the bronchioles so the patient can cough up that junk."
My point by relaying this conversation is this: why is it that we folks with the facts on our side always have to be on the defense? Why do we have to prove that we are right? Now, I'm not perfect, but I think I have my bronchodilator wisdom down pretty well. I have actually studied it. I've read books. I read every magazine article I can on the topic.
In fact, I even read the package insert once, which states, "This medicine is for asthma and COPD to treat bronchospasm." So, what is bronchospasm? Bronchospasm is the spasming of muscles. Ahem, there are no muscles in the alveioli to spasm.
I know! I know why people like you and me who have the facts on our side have to defend ourselves. I know why we are always on the defense. It's because it's easier to be ignorant. It's easier to believe in fallacies that make us feel good about ourselves, than to think. It actually makes those RNs and DRs feel good about themselves to order a a breathing treatment because it makes them feel they are doing something good for the patient. It's easier to believe in hoax theories and bronchodilator fallacies than to think.
Yet I'm being lazy. All us RTs are being lazy when we question why a bronchodilator is being ordered. We are lazy because we think we RTs with science on our side, two years of studying bronchodilators at school, and 14 years experience should decide who gets breathing treatments and not some a doctor or nurse and their fake science.
It's the same way with the crowd of people that aren't so quick to believe in global warming. They are lazy and refuse to believe in science. Yet they are the ones who look at the same science and see that the facts show inconclusive results. We must not be to quick to judge, and be more open minded to the facts at hand. We must not be sheep caught up in a movement.
Ladies and gentlemen, this is why it's frustrating to be a thinker. This is why it is frustrating to be a person who always reads to learn the facts. This is why there is so much apathy by RTs because we know the facts and yet no one will listen. They choose to believe the fallacies because it's easier to be ignorant than it is to pick up a book or magazine and read.
Am I the only one to ask questions like this? I doubt it, although I don't think there are many of us.
I have two examples to what I'm questioning here: global warming and bronchodilator usage.
We've been studying weather patters for over 100 years not. If you put that into consideration, that's 100 years in something like 100+ billion years. If you do the math, I bet that's a shorter amount of time that 0.00000000000001% of our history. Yet, based on the numbers we have accumulated, people have come to a conclusion.
I find this funny, because most scientists (as you can see by this post) are still questioning the science. Not even scientists can come to a logical conclusion regarding global warming. Yet you have a majority of politicians willing change our economic landscape based on this theory, and a majority of the world population willing to buy into it.
To be honest here, I am neither a believer nor a disbeliever in the theory of global warming. I think it's best to let science decide. It's best to look at the trends which show constant periods of warming, followed by periods of cooling, and so forth.
Yet some people fail to look at this big picture, and they make political opinions based on the current trend. For example, in the 1970s the trend was toward global cooling, and you had scientists actually proposing melting the polar ice caps to warm the planet. Aren't we glad that never happened?
From the late 1970s to about 1998 the trend trended upward, and you had the global warming scare which is ongoning, despite stagnant global temps since 2000.
You have people like the honorable Al Gore claiming that if we don't clean up our planet it won't exist in 10 years. To me, this is a scare to get people to send more money his way. It's all about money. It's all about selling a political view over science.
Personally, I think it's a good idea to be environmentally conscious. I think it's a good idea to reduce, reuse and recycle. I think it's a good idea to look for alternative energy sources. Yet let's not get drastic and force one view based on a theory.
The same can be said of bronchodilators like Ventolin. You have doctors and nurses believing that Ventolin is needed every time they hear a wheeze or see a short of breath patient. Yet the science proves otherwise.
Still, when you go to correct a nurse or a doctor, when you share the facts and the science about bronchodilators, they say that I am being lazy. A great example of this occurred last night when I was called to do a breathing treatment for a person who was dyspneic due to pneumonia.
I approached the nurse and said, "You know Ventolin does nothing for pneumonia."
She said, "Yes it does. It opens the airways and helps the patient cough up the pneumonia."
"That's a fallacy," I said. "Science has proven that Ventolin is a bronchodilator you are right. But pneumonia does not cause bronchoconstriction, so the air passages in that person's lungs are already dilated. Thus, a bronchodilator will not expand these air passages beyond what they already are. In fact, there is no need to because pneumonia is not in the bronchioles. There are no secretions trapped in the bronchioles."
"Where did you hear that from?" the nurse said angrily.
"Not only that," I said, continuing on with the facts I've learned through my many years of research, "Pneumonia is a disease of inflammation of the alveoli. Bronchodilators don't treat inflammation, that's the job of corticosteroids and perhaps even antibiotics to kill the bacteria down there if it's bacterial, which it usually is.
"Likewise, I added," her face was red as a beat by now, "Ventolin is 0.5 microns, just the perfect size to fit into the air passages to get to the beta one receptors there. The Alveoli are 0.1-0.2 microns wide, so Ventolin doesn't even get down there.
"And to top that off," I said patting the side of the nurses station in my confident rage, "I don't even believe there are beta adrenergic receptors in the alveioli."
"You're just trying to get out of work," she said. She smiled. She's a great person, although she needed the education regardless that it was going to sink in or not.
By this time Dr. Q1 is standing right next to her, and she interjected: "Jill is right. Ventolin relaxes the bronchioles so the patient can cough up that junk."
My point by relaying this conversation is this: why is it that we folks with the facts on our side always have to be on the defense? Why do we have to prove that we are right? Now, I'm not perfect, but I think I have my bronchodilator wisdom down pretty well. I have actually studied it. I've read books. I read every magazine article I can on the topic.
In fact, I even read the package insert once, which states, "This medicine is for asthma and COPD to treat bronchospasm." So, what is bronchospasm? Bronchospasm is the spasming of muscles. Ahem, there are no muscles in the alveioli to spasm.
I know! I know why people like you and me who have the facts on our side have to defend ourselves. I know why we are always on the defense. It's because it's easier to be ignorant. It's easier to believe in fallacies that make us feel good about ourselves, than to think. It actually makes those RNs and DRs feel good about themselves to order a a breathing treatment because it makes them feel they are doing something good for the patient. It's easier to believe in hoax theories and bronchodilator fallacies than to think.
Yet I'm being lazy. All us RTs are being lazy when we question why a bronchodilator is being ordered. We are lazy because we think we RTs with science on our side, two years of studying bronchodilators at school, and 14 years experience should decide who gets breathing treatments and not some a doctor or nurse and their fake science.
It's the same way with the crowd of people that aren't so quick to believe in global warming. They are lazy and refuse to believe in science. Yet they are the ones who look at the same science and see that the facts show inconclusive results. We must not be to quick to judge, and be more open minded to the facts at hand. We must not be sheep caught up in a movement.
Ladies and gentlemen, this is why it's frustrating to be a thinker. This is why it is frustrating to be a person who always reads to learn the facts. This is why there is so much apathy by RTs because we know the facts and yet no one will listen. They choose to believe the fallacies because it's easier to be ignorant than it is to pick up a book or magazine and read.
Wednesday, July 22, 2009
RT Cave Rule #36: "Come on! Come on!"
I first met Dr. Stevens in one of the most stressful and inconvenient places for a code to take place: the small cat scan room. On the way I took the time to grab my little black airway box and was a few seconds behind the nursing supervisor in arriving. Before even entering the room I could hear the ominous sound of air rushing through the Ambu-bag.
"Come on! Come on!" the anesthesiologist was saying as he was hovering over the head of the bed of the patient of whom he was bagging. "I need a size 8 ETT already," he said with an irritable expression while holding out his hand and wiggling his fingers impatiently.
I set the black bocks down, ripped off the white lock, and fumbled for the right tube. I found it and set to check the cuff...
"Come on! Come on!"
There's only so fast I can get things done here! I thought to say, but held my tongue, knowing such comments only cause more trouble than it's worth. I took the time grab a syringe, inserted it into the cuff line, and pushed air into it. As usual the cuff was fine.
Come on! Come on!" his fingers wriggling like a little boy waiting for the clown in a parade to toss a lump of candy in his direction. "Come on! Come on!"
I grabbed the surgilube, but cast it aside in favor of handing it to the doc. If you want it lubed you can spit a lug on it, I thought. I pushed my way to the head of the bed and held pressure against the patients crichoid, felt the tube slip through the vocal cords, an made my way to grab the tube to secure it, which is usually my job at this point.
"Secure the tube already! Come on! Come on!" He was holding onto the tube, not willing to let go of it. That's a trait of that only anesthesiologists have. All other docs, as far as I've ever seen, are more than eager for RTs to take over grip of the entdotracheal tube.
I pushed my way through the crowded room where all seven folks now peasant were shoulder to shoulder. I grabbed the airway protector and rushed back to the bed. Due to the crowd, the steaming hot pressure down my spine, sweat now dripping from my forehead, this took about a minute to accomplish, way to long for Dr. prick over there.
"Come on already! We need to get this airway secure!"
I secured the tube. The patient was saved. I took over the airway. I thanked the doctor for all his hard work. He told me rudely I need to be quicker. I smiled told him he did a great job with this patient to boost his ego.
Three years later I stood over the head of the bed bagging a patient in the critical care. The
man with pneumonia in the one cancerous lung he had left was breathing at that rapid, deep rate people starving for air usually do, screaming, "I...," gasp, "need...," gasp, "AIR!"
He had that ominous, distant look in his eyes. I had no choice but to start breathing for him. Knowing Dr. Stevens, or Dr. Come on as I call him behind his back, I had three tubes ready with three syringes connected to the cuff pilot, and a stilet in each freshly lubed tubes ready to slide into the gullet of the patient.
Dr. Come on asked for the size eight and I handed it to him. "Give the succs now!" he ordered to the nurses.
"It's coming," I heard Arny say as he rushed into the room drawing up the medicine as he worked his way to the head of the bed.
"Come on! Come on!" Chanted the doc with the vexed countenance I had gotten to know so well over the years. "Come on! Come on!"
At last it was not just me he became vexed, impatient with. Now it was the nurse that was at the root at his sudden mood change. Or, I now wondered, was he always this way, going home perhaps to be irritated with his wife for not lighting his cigarette fast enough.
Yet, upon leaving the room, I said, "Thanks for coming, Dr. com... Dr. Stevens. You saved us from being worried about this patient the rest of the night."
And this made me think of RT Cave Rule # 36, of which we will also include under Dr. Wisdom in case such a doctor might wish to learn what RTs think of their needless irritability:
Most doctors, in my opinion, are very patient and very cordial during a code, especially codes that are in places of the hospital we usually don't have coded (like small rooms), and codes on the young, codes on prominent members of the community, and those we know.
Yet there are those, like Dr. Come on, who are impatient to wait the extra 55 seconds for the RT to check the cuff, and for the RN to draw up the right dose of medicine.
"Come on! Come on!" the anesthesiologist was saying as he was hovering over the head of the bed of the patient of whom he was bagging. "I need a size 8 ETT already," he said with an irritable expression while holding out his hand and wiggling his fingers impatiently.
I set the black bocks down, ripped off the white lock, and fumbled for the right tube. I found it and set to check the cuff...
"Come on! Come on!"
There's only so fast I can get things done here! I thought to say, but held my tongue, knowing such comments only cause more trouble than it's worth. I took the time grab a syringe, inserted it into the cuff line, and pushed air into it. As usual the cuff was fine.
Come on! Come on!" his fingers wriggling like a little boy waiting for the clown in a parade to toss a lump of candy in his direction. "Come on! Come on!"
I grabbed the surgilube, but cast it aside in favor of handing it to the doc. If you want it lubed you can spit a lug on it, I thought. I pushed my way to the head of the bed and held pressure against the patients crichoid, felt the tube slip through the vocal cords, an made my way to grab the tube to secure it, which is usually my job at this point.
"Secure the tube already! Come on! Come on!" He was holding onto the tube, not willing to let go of it. That's a trait of that only anesthesiologists have. All other docs, as far as I've ever seen, are more than eager for RTs to take over grip of the entdotracheal tube.
I pushed my way through the crowded room where all seven folks now peasant were shoulder to shoulder. I grabbed the airway protector and rushed back to the bed. Due to the crowd, the steaming hot pressure down my spine, sweat now dripping from my forehead, this took about a minute to accomplish, way to long for Dr. prick over there.
"Come on already! We need to get this airway secure!"
I secured the tube. The patient was saved. I took over the airway. I thanked the doctor for all his hard work. He told me rudely I need to be quicker. I smiled told him he did a great job with this patient to boost his ego.
Three years later I stood over the head of the bed bagging a patient in the critical care. The
man with pneumonia in the one cancerous lung he had left was breathing at that rapid, deep rate people starving for air usually do, screaming, "I...," gasp, "need...," gasp, "AIR!"
He had that ominous, distant look in his eyes. I had no choice but to start breathing for him. Knowing Dr. Stevens, or Dr. Come on as I call him behind his back, I had three tubes ready with three syringes connected to the cuff pilot, and a stilet in each freshly lubed tubes ready to slide into the gullet of the patient.
Dr. Come on asked for the size eight and I handed it to him. "Give the succs now!" he ordered to the nurses.
"It's coming," I heard Arny say as he rushed into the room drawing up the medicine as he worked his way to the head of the bed.
"Come on! Come on!" Chanted the doc with the vexed countenance I had gotten to know so well over the years. "Come on! Come on!"
At last it was not just me he became vexed, impatient with. Now it was the nurse that was at the root at his sudden mood change. Or, I now wondered, was he always this way, going home perhaps to be irritated with his wife for not lighting his cigarette fast enough.
Yet, upon leaving the room, I said, "Thanks for coming, Dr. com... Dr. Stevens. You saved us from being worried about this patient the rest of the night."
And this made me think of RT Cave Rule # 36, of which we will also include under Dr. Wisdom in case such a doctor might wish to learn what RTs think of their needless irritability:
RT Cave Rule #36: It is not necessary for doctors to get irritated with RNs and RTs for doing the jobs they are prepared and fully qualified to do during a code. Getting irritated only makes those around you more stressed in a situation that is already stressful."
Most doctors, in my opinion, are very patient and very cordial during a code, especially codes that are in places of the hospital we usually don't have coded (like small rooms), and codes on the young, codes on prominent members of the community, and those we know.
Yet there are those, like Dr. Come on, who are impatient to wait the extra 55 seconds for the RT to check the cuff, and for the RN to draw up the right dose of medicine.
Saturday, July 18, 2009
Indications for breathing treatments
Since I write so often on these pages reasons nurses call for breathing treatments and doctors order them (my latest version is here), I think it is due time I create a list of the true indications for a bronchodilator breathing treatments.
Keep in mind a bronchodilator only treats bronchospasm. Likewise, rescue inhalers used properly with spacer are proven to be as effective in most cases as a breathing treatments.
That in mind, here we go:
Keep in mind a bronchodilator only treats bronchospasm. Likewise, rescue inhalers used properly with spacer are proven to be as effective in most cases as a breathing treatments.
That in mind, here we go:
- Asthma
- Bronchitis (acute or chronic)
- Emphysema (actually, this is not a true indication)
- Cistic Fibrosis
- Airway swelling due to allergic reaction (actually, bronchodilator doesn't treat swelling)
- Pt with above diseases who cannot manage an inhaler (Albuterol, Atrovent, Flovent, etc.)
- Bronchospasm secondary to other disease process such as CHF, pneumonia, pulmonary fibrosis, RSV, lung cancer, sinusitis, bronchiectasis, etc.
- Bronchospasm secondary to allergic reaction (bee sting)
Note #1: The diseases in #8 do not necessarily cause bronchospasm, but may irritate the sensitive airways of people who have the diseases mentioned above
Note #2: It appears doctors believe treatments are cures for all ailments, and are indicated for all the wheezes and all that causes shortness of breath as you can see for yourself by reading the Real Physician's Creed.
We'll make this RT Cave Rule #25: A wise medical care worker will know the indications for ordering a breathing treatment and not request a treatment (or order one, or give one) unless a patient meets this criteria.
Note #3: Again, I am going to file this under humor, although it is not humor it is serious. Too many doctors fail to understand the true indications for breathing treatments
Friday, July 17, 2009
28 non indications for breathing treatment
Just a friendly reminder: the following are not indications for bronchodilator breathing treatments:
- Dr. ordered it
- Don't know what else to do
- Nurse wanted it
- Pt wanted it
- Stridor
- Sinusitis
- Mesothelioma
- Lupus
- Laryngospasm
- Audible wheeze
- Rhonchi
- Crackles
- M.S.
- Homeless
- Depression
- Pt has home nebs
- Pt likes tx
- Pt likes company
- Bed ridden
- History of smoking
- Irritating lung sounds
- Low SpO2
- Trach
- Intubated
- Post operative
- Atelectasis
- Fever
- Heart failure
- Cardiac wheeze
- Pneumonia
- Pleural effusion
- Pneumo
- Rickits
- RSV
- ARDS
- RDS
- P.E.
- Cough
- Sputum induction
- All wheezes (all that wheezes is not bronchospasm)
- All SOB (SOB is not always caused by bronchospasm)
- Just because the patient is wearing a mask
Sunday, May 10, 2009
RT Cave Rule #35: Wise Dr.s, Humble RTs
Wicked busy here at the RT Cave. I suppose it wouldn't be so hard if there were two of us here at night, but since it's just little old me all by myself trying to waddle between 17 patients, it makes for a strenuous night.
The short of breath patients, the critical patients in the ER, the one's who need BiPAP, the ventilated patients, and the one's who require a certain degree of RT expertise and critical thinking are the patients who bring joy and pride to the RT. They are the reason most of us chose this profession.
The frustration comes from the other 80% of the job. The frustration comes from the 16 patients who have no need for a bronchodilator every 4-6 hours around the clock. And once our feet are burning from trudging room to room trying to get all these done in a timely manner, the emergency calls us down for a lady in respiratory distress.
"Oh, come on!" The Rt grumbles. Yet he reminds himself that it is not this lady in respiratory distress, the one who requires his time and expertise for the next two hours, that he is mad at. She is the reason he loves his job. It's the critical thinking he does that saves her life that brings him joy.
And, yes, when the doctor wanted to intubate the patient, and the RT thought to say to the wise doctor: "How about if we try BiPAP first?"
But the BiPAP didn't make that CO2 of 89 drop. In fact, the CO2 actually rose to 92. The doctor called and asked to talk with the RT. He said, "If we can't get that CO2 down we will have to intubate. Do you have any ideas?"
The RT was impressed with the doctor. It's not very often a doctor utilizes the wisdom of the RT. And, seizing the moment, the RT knew exactly what to say: "We could increase the IPAP in an attempt to raise her tital volume and blow off the excess CO2."
"Go for it!" the doctor said.
An hour after the the humble RT called in the repeat blood gases to the doctor. The RT said, "Look, here's what I did. I increased the IPAP from 10 to 16 in an attempt to increase the tital volume and blow off CO2. The patient is now getting an estimated tidal volume of 550-600, which fit into the hospital tidal volume protocol of 6-10cc/kg ideal body weight.
"Then," the RT continued, "since the PO2 was fine with the last gas, I decreased the epap from 5 to 4 to get a pressure support of 12 and a little extra tidal volume. That said, the CO2 is down from 90 to 86, the pH is up from 7.29 to 7.31. Aside from that, the patient is awake and alert and orientated on or off the BiPAP. She is not longer in respiratory distress and states she actually feels great now. Oh, and she's also joking with us."
The good doctor said, "Good job! I think we averted a ventilator for now."
The RT's ego jumped from zero to one. But the humble RT had no time to savor the moment, as another page to the ER meant another treatment for a CHF patient. And, hence is the life and times of an RT.
Ego = +1. But the ego of the RT doesn't matter. A doctor being wise and admitting he needed the education, training and wisdom of his RT for a change does not matter. What matters is neither the doctor nor the RT panicked and needlessly intubated the patient.
This is a perfect example of what good can come from all the medical staff working together. And, since we haven't done this in a while, it's time for RT Cave Rule #35.
Regardless: ego = +1. Current ego status = 1.
The short of breath patients, the critical patients in the ER, the one's who need BiPAP, the ventilated patients, and the one's who require a certain degree of RT expertise and critical thinking are the patients who bring joy and pride to the RT. They are the reason most of us chose this profession.
The frustration comes from the other 80% of the job. The frustration comes from the 16 patients who have no need for a bronchodilator every 4-6 hours around the clock. And once our feet are burning from trudging room to room trying to get all these done in a timely manner, the emergency calls us down for a lady in respiratory distress.
"Oh, come on!" The Rt grumbles. Yet he reminds himself that it is not this lady in respiratory distress, the one who requires his time and expertise for the next two hours, that he is mad at. She is the reason he loves his job. It's the critical thinking he does that saves her life that brings him joy.
And, yes, when the doctor wanted to intubate the patient, and the RT thought to say to the wise doctor: "How about if we try BiPAP first?"
But the BiPAP didn't make that CO2 of 89 drop. In fact, the CO2 actually rose to 92. The doctor called and asked to talk with the RT. He said, "If we can't get that CO2 down we will have to intubate. Do you have any ideas?"
The RT was impressed with the doctor. It's not very often a doctor utilizes the wisdom of the RT. And, seizing the moment, the RT knew exactly what to say: "We could increase the IPAP in an attempt to raise her tital volume and blow off the excess CO2."
"Go for it!" the doctor said.
An hour after the the humble RT called in the repeat blood gases to the doctor. The RT said, "Look, here's what I did. I increased the IPAP from 10 to 16 in an attempt to increase the tital volume and blow off CO2. The patient is now getting an estimated tidal volume of 550-600, which fit into the hospital tidal volume protocol of 6-10cc/kg ideal body weight.
"Then," the RT continued, "since the PO2 was fine with the last gas, I decreased the epap from 5 to 4 to get a pressure support of 12 and a little extra tidal volume. That said, the CO2 is down from 90 to 86, the pH is up from 7.29 to 7.31. Aside from that, the patient is awake and alert and orientated on or off the BiPAP. She is not longer in respiratory distress and states she actually feels great now. Oh, and she's also joking with us."
The good doctor said, "Good job! I think we averted a ventilator for now."
The RT's ego jumped from zero to one. But the humble RT had no time to savor the moment, as another page to the ER meant another treatment for a CHF patient. And, hence is the life and times of an RT.
Ego = +1. But the ego of the RT doesn't matter. A doctor being wise and admitting he needed the education, training and wisdom of his RT for a change does not matter. What matters is neither the doctor nor the RT panicked and needlessly intubated the patient.
This is a perfect example of what good can come from all the medical staff working together. And, since we haven't done this in a while, it's time for RT Cave Rule #35.
RT Cave Rule #35: A wise doctor admits when he is to the limits of his medical wisdom and seeks the education, experience and wisdom of RTs. A wise RT will be ready with a veritable option for the doctor, and stay humble if he is right.
Regardless: ego = +1. Current ego status = 1.
Saturday, April 11, 2009
MCAT question #32
I cannot reveal my source, but I once again am privy to esoteric wisdom. The following is a question I have obtained from the Medical College Admission Exam (MCAT):
#32:
Pidley and annoying Respiratory Therapists are trained that Albuterol and Xoponex are medicines used to treat and relieve the symptoms of Asthma and COPD. That in mind, which of the following diseases are really treated and cured with these bronchodilators:
#32:
Pidley and annoying Respiratory Therapists are trained that Albuterol and Xoponex are medicines used to treat and relieve the symptoms of Asthma and COPD. That in mind, which of the following diseases are really treated and cured with these bronchodilators:
- a. respiratory failure of any origin
- b. pneumonia
- c. pneumonia
- d. bilateral pneumonia
- e. pneumonia
- f. pneumonia
- g. pneumonia
- h. hernia
- i. fractured leg
- j. Lysis
- k. RSV
- l. pre nop
- m. sepsis
- n. asthma
- o. COPD
- p. rickets
- q. n & o
- r. b, c ,e, f & g
- s. b, c, d, e, f, g & k
- t. b, c, d, e, f & g
- u. a, b, c, d, e, f, & g
- v. h, i, j, l, & m
- w. none of the above
- x. all of the above
- y. all of the above and many more diseases
- z. I don't know. I forgot to do my homework.
Sunday, December 21, 2008
The best doctors are open minded
A doctor who is open minded and courteous can have a beneficial effect not just on the ego of an RT, but can benefit the patient as well. Can you imagine that?
Yet we have one doctor I like to refer to as Dr. Q1 who never seems to listen to me when I make recommendations. She is adamantly opposed to RT Driven Protocols because no RT could know when a therapy is indicated more than a doctor.
When a patient is in respiratory distress I'd obviously take care of the patient first. But there are some patients I think could use a second treatment right now that I don't bother talking to Dr. Q1 about because she'll just say, "No. I ordered them Q1."
Hence the name I chose for her.
So now when I think a patient could use a treatment when Dr. Q1 is on I just go about my business because I'm so tired of being rejected. I feel bad for the patients sometimes that they have to wait an hour to catch their breath because they have a know-it-all doctor. But, that's the way it is sometimes in hospital politics.
Of course then we have most doctors, of whom are open minded to ideas. It's Doctors like this who will "discuss" open mindedly options with their RTs.
Which is why tonight, when I had a patient who wasn't really SOB but just looked like he might benefit from a treatment, I recommended such to the doctor.
The peek flow increased from 450 to 550 after the Ventolin treatment was given even though the patient didn't notice any change in his breathing. Instead of being sent home with only antibiotics to fight the pneumonia, the patient was sent home with a Ventolin inhaler for his bronchospasm.
Ah, the doctor was impressed. The patient benefited. And the RTs ego went up a notch.
You see, there is this thing called team work. We are a team. Yet, when you have a doctor who sits above everyone else, who walks around lopsided because her head is so swelled up with ego, patients suffer as a result.
Yet we have one doctor I like to refer to as Dr. Q1 who never seems to listen to me when I make recommendations. She is adamantly opposed to RT Driven Protocols because no RT could know when a therapy is indicated more than a doctor.
When a patient is in respiratory distress I'd obviously take care of the patient first. But there are some patients I think could use a second treatment right now that I don't bother talking to Dr. Q1 about because she'll just say, "No. I ordered them Q1."
Hence the name I chose for her.
So now when I think a patient could use a treatment when Dr. Q1 is on I just go about my business because I'm so tired of being rejected. I feel bad for the patients sometimes that they have to wait an hour to catch their breath because they have a know-it-all doctor. But, that's the way it is sometimes in hospital politics.
Of course then we have most doctors, of whom are open minded to ideas. It's Doctors like this who will "discuss" open mindedly options with their RTs.
Which is why tonight, when I had a patient who wasn't really SOB but just looked like he might benefit from a treatment, I recommended such to the doctor.
The peek flow increased from 450 to 550 after the Ventolin treatment was given even though the patient didn't notice any change in his breathing. Instead of being sent home with only antibiotics to fight the pneumonia, the patient was sent home with a Ventolin inhaler for his bronchospasm.
Ah, the doctor was impressed. The patient benefited. And the RTs ego went up a notch.
You see, there is this thing called team work. We are a team. Yet, when you have a doctor who sits above everyone else, who walks around lopsided because her head is so swelled up with ego, patients suffer as a result.
Friday, December 19, 2008
This RT is impressed tonight
I was in the process of doing an EKG while Tracy, the new nurses practitioner, questioned the patient. The NP said, "Does your chest pain hurt more when you take a deep breath?"
"No," the pt. said. "But my doctor did put me on breathing treatments when I saw him last week."
"Why were you put on treatments?"
"Because the doctor said the treatment would help loosen up phlegm from the part of the lung the pneumonia was and help me feel better. But I don't notice a bit of difference and I've taken them now for two weeks."
"Well," the NP said, "That's not what treatments are for."
My face lit up. Tracy looked up at me and smiled. She worked with me years ago on nights. She learned well.
---------------------
So, then I ended up back in the ER 30 minutes later with Tracy and the ER Doc standing next to us, "So, I just don't think when that guys doctor says Ventolin will thin secretions that that's the purpose of the medicine, don't you think?"
"Absolutely," I said. "The medicine doesn't even go to that part of the lung the pneumonia is. But, believe it or not, our protocol upstairs has us doing Ventolin every 6 hours on all pneumonia patients."
The old ER doc said, "I guess they just want to assume Ventolin cures everything and not just bronchospasm."
This RT was impressed. Wow! Not only is the new NP educated properly about Ventolin, so is the old ER Doc.
This is a step forward in the battle for bronchodilator reform.
"No," the pt. said. "But my doctor did put me on breathing treatments when I saw him last week."
"Why were you put on treatments?"
"Because the doctor said the treatment would help loosen up phlegm from the part of the lung the pneumonia was and help me feel better. But I don't notice a bit of difference and I've taken them now for two weeks."
"Well," the NP said, "That's not what treatments are for."
My face lit up. Tracy looked up at me and smiled. She worked with me years ago on nights. She learned well.
---------------------
So, then I ended up back in the ER 30 minutes later with Tracy and the ER Doc standing next to us, "So, I just don't think when that guys doctor says Ventolin will thin secretions that that's the purpose of the medicine, don't you think?"
"Absolutely," I said. "The medicine doesn't even go to that part of the lung the pneumonia is. But, believe it or not, our protocol upstairs has us doing Ventolin every 6 hours on all pneumonia patients."
The old ER doc said, "I guess they just want to assume Ventolin cures everything and not just bronchospasm."
This RT was impressed. Wow! Not only is the new NP educated properly about Ventolin, so is the old ER Doc.
This is a step forward in the battle for bronchodilator reform.
Friday, October 17, 2008
Dr. Q1
Jim Buterol is a fellow respiratory therapist who works at a famous hospital down south. I'm not going to reveal his real name to protect him. He told me that where he works there is a doctor that he refers to as Dr. Q1. Her real name is Dr. Krane, but that's not a real name either. She loves to order breathing treatments Q1 until discharge.
It gets old after a while, he said. While most doctors would at least assess the patient before ordering medicines, this doctor, once she learns a patient has shortness of breath, orders albuterol Q1 automatically.
I told my friend that I think this doctor is smart. He said, "Why?" I said, "Because she knows exactly when patients are going to be short of breath."
He laughed. But it really wasn't funny. It was actually horrible. In many cases this resulted in wasted medicine and resulted in a poor use of the respiratory therapists time.
In many cases, my friend said he would be in the emergency room tending to these patients who were, in many cases, no longer short of breath by the time the second, third, fourth, fifth and sixths treatments were being given. In many cases there were other patients he had to attend to but couldn't because he was in ER taking care of his Q1 treatments.
He said he complained to his bosses, but they said the job of the RT is to do whatever the doctor says. So, he decided, there was no point in further complaining. He said after a while he became burned out and apathetic.
We have similar stuff that goes on here at Shoreline. I talked to my boss this morning, and she said I did twice as many procedures last night as the other night shift worker the night before, and we both had the same number of patients.
I said, "That's because Dr. Q1 was working." She didn't understand what I was talking about, so she ignored me. I was fine with that. I didn't want to explain to her why I said that anyway.
When I gave report I said, "Dr. Q1 worked last night." My coworker understood immediately what I was referring to. It's sort of an inside joke, I guess. It's code language only RTs understand.
I wrote before that I think it's neat when a doctor is smart enough to know a patient will be short-of-breath and exactly when. How the heck does she know a patient is going to be short-of-breath every hour? We may never know.
Funny thing is, she's wrong most of the time. Most of the time, as I noted above, patients are not short of breath when they are ordered. But, who are we, as humble RTs, to argue with a doctor? Are there an Q1 doctors where you work? I have a sneaking suspicion that there are.
It gets old after a while, he said. While most doctors would at least assess the patient before ordering medicines, this doctor, once she learns a patient has shortness of breath, orders albuterol Q1 automatically.
I told my friend that I think this doctor is smart. He said, "Why?" I said, "Because she knows exactly when patients are going to be short of breath."
He laughed. But it really wasn't funny. It was actually horrible. In many cases this resulted in wasted medicine and resulted in a poor use of the respiratory therapists time.
In many cases, my friend said he would be in the emergency room tending to these patients who were, in many cases, no longer short of breath by the time the second, third, fourth, fifth and sixths treatments were being given. In many cases there were other patients he had to attend to but couldn't because he was in ER taking care of his Q1 treatments.
He said he complained to his bosses, but they said the job of the RT is to do whatever the doctor says. So, he decided, there was no point in further complaining. He said after a while he became burned out and apathetic.
We have similar stuff that goes on here at Shoreline. I talked to my boss this morning, and she said I did twice as many procedures last night as the other night shift worker the night before, and we both had the same number of patients.
I said, "That's because Dr. Q1 was working." She didn't understand what I was talking about, so she ignored me. I was fine with that. I didn't want to explain to her why I said that anyway.
When I gave report I said, "Dr. Q1 worked last night." My coworker understood immediately what I was referring to. It's sort of an inside joke, I guess. It's code language only RTs understand.
I wrote before that I think it's neat when a doctor is smart enough to know a patient will be short-of-breath and exactly when. How the heck does she know a patient is going to be short-of-breath every hour? We may never know.
Funny thing is, she's wrong most of the time. Most of the time, as I noted above, patients are not short of breath when they are ordered. But, who are we, as humble RTs, to argue with a doctor? Are there an Q1 doctors where you work? I have a sneaking suspicion that there are.
Wednesday, September 24, 2008
There's no such thing as coarse lung sounds
The rest of this week I thought I would discuss some of the basic lungsounds. I know this might sound hilarious, but there are some people who have listened to lungs for 20 years and still have no clue how to describe them.
To be fair, however, different books can describe the same sounds differently. Lets take crackles for instance. Some books say that a crackle is either fine, medium or coarse, while others say it's rhonchi, rhales and fine crackles.
On a side note, someone in my RT department (we won't name names) keeps charting "Coarse" under lungsounds. Allow me to share this information with you: there is no such lung sound as coarse.
What is coarse? Is it a coarse wheeze? Is is rhonchi? Actually, it could be both. It could be a coarse wheeze or coarse rhonchi. But, so, where is it? RUL? RML? RLL? LUL? LLL?
So we need to be more specific.
The majority of the time, however, a coarse wheeze is actually rhonchi. if you can isolate it to one particular lobe, its more likely a wheeze. But if it's continuous throught all the lungfields, it is probably not a wheeze.
Why do I say this? Because rhonchi is usually heard over a wheeze and is usually hard throughout the lungs. The low pitched coarseness of rhonchi is usually in the upper, larger airways where sound travels better, and it produces a noise that is more easily heard.
A wheeze, for definition purposes, is not a low pitched coarse sound but high pitched whistling sound. And because it comes from the small bronchial tubes in the lungs, it is NEVER heard audibly. I will discuss wheezes at a later date.
Today I want to discuss rhonchi and coarse.
There was a practice NBRC test that asked this question: You are listening to lung sounds and you hear a coarse sound throughout on inspiration and expiration. How do you best describe this sound? a) a wheeze b) rhonchi c) crackles d) a and c.
Do you want to know what the answer was? It was (drum roll please) "b" rhonchi.
If you are charting coarse, you should actually be charting rhonchi. In a lot of patients you have that loud sound on inspiratory and expiratory. It may even sound like snoring. This is not a wheeze, it is rhonchi. What you are hearing is secretions rumbling on inspiratoin and expiration.
This is probably the toughest lung sound to pick out because it's not taught very well in school. Even many doctors chart this is coarse or as a wheeze and assume it is bronchospasm.
Yet, as soon as the RT does the STAT breathing treatment, the patient feels no better and the peek flow is the same before and after. Yet, three weeks later and after the insurance company is out $10,000 because of useless breathing treatments, the patient still has those treatments ordered.
And all of that because the doctor heard rhonchi and had no idea it was not a wheeze.
Rhonchi can also produce a bubbly sound over the throat and upper airway, which almost sounds like fluid is in there. You have the patient cough and usually this goes away. However, sometimes those secretions are further embedded in the upper airway, and this causes the COARSE sound you hear.
Sometimes these secretions are embedded by the vocal cords, and produce an audible sound. As I wrote in my last post, any lung sound that is audible is not a wheeze: it is rhonchi. Either that, or it is stridor.
Stridor is usually an audible inspiratory high-pitched sound. It is usually caused because of swelling near the vocal cords. It can be the result of croup or post extubation. It can be caused due to laryngospasms. And, despite contrary belief, it is a common lung sound in adults too. Only, it usually gets charted as a wheeze, so no one ever talks about it.
However, some RT books describe stridor as any noise inspiratory and expiratory that is heard in the throat. (Dana Oakes, "Clinical Practitioner's Pocket Guide to Respiratory Therapy," describes it this way).
To hear this noise, all you have to do is take your stethoscope and set it over the throat. If you hear it loud and clear their, then the noise you heard in the lower airways was this same sound.
Yet, it is true, many times doctors only listen to the posterior lungs and hear this high pitched sound and call it a wheeze, when it is actually upper airway stridor or rhonchi. A lot of older patients get secretions stuck right up behind the vocals, and they produce this high pitched sound. This happens sometimes for no reason on healthy adults, or it can happen on those with NGs, or simply OTL (Out To Lunch) patients or SGD (She's gonna die) patients.
I'm to the point now that I get so irritated when a doctor orders a treatment because a patient has upper airway swelling or secretions and no otherwise signs of shortness of breath, that if the doctor is still standing there, I will listen to the throat and say, "What you hear isn't a wheeze, it's stridor."
"Don't you know a wheeze by now," a doctor said to me once.
"Yes, and that's a stridor."
Of course I don't do that very often, only when I'm extremely busy and don't have time for such nonsensical treatments, very tired, or simply irritated. Unfortunately that doesn't happen enough around here, so our doctors continue to go uneducated.
Now I say doctors, I know there are some nurses and even a few RTs who have no clue what lung sounds are actually bronchospasm and which are secretions. I suppose this will be a continual battle.
However, there are some really smart doctors and RNs that I work with who know the difference, and don't call me every time they hear "COARSE" lung sounds.
Tomorrow I will expound a little about crackles and then maybe wheezes.
To be fair, however, different books can describe the same sounds differently. Lets take crackles for instance. Some books say that a crackle is either fine, medium or coarse, while others say it's rhonchi, rhales and fine crackles.
On a side note, someone in my RT department (we won't name names) keeps charting "Coarse" under lungsounds. Allow me to share this information with you: there is no such lung sound as coarse.
What is coarse? Is it a coarse wheeze? Is is rhonchi? Actually, it could be both. It could be a coarse wheeze or coarse rhonchi. But, so, where is it? RUL? RML? RLL? LUL? LLL?
So we need to be more specific.
The majority of the time, however, a coarse wheeze is actually rhonchi. if you can isolate it to one particular lobe, its more likely a wheeze. But if it's continuous throught all the lungfields, it is probably not a wheeze.
Why do I say this? Because rhonchi is usually heard over a wheeze and is usually hard throughout the lungs. The low pitched coarseness of rhonchi is usually in the upper, larger airways where sound travels better, and it produces a noise that is more easily heard.
A wheeze, for definition purposes, is not a low pitched coarse sound but high pitched whistling sound. And because it comes from the small bronchial tubes in the lungs, it is NEVER heard audibly. I will discuss wheezes at a later date.
Today I want to discuss rhonchi and coarse.
There was a practice NBRC test that asked this question: You are listening to lung sounds and you hear a coarse sound throughout on inspiration and expiration. How do you best describe this sound? a) a wheeze b) rhonchi c) crackles d) a and c.
Do you want to know what the answer was? It was (drum roll please) "b" rhonchi.
If you are charting coarse, you should actually be charting rhonchi. In a lot of patients you have that loud sound on inspiratory and expiratory. It may even sound like snoring. This is not a wheeze, it is rhonchi. What you are hearing is secretions rumbling on inspiratoin and expiration.
This is probably the toughest lung sound to pick out because it's not taught very well in school. Even many doctors chart this is coarse or as a wheeze and assume it is bronchospasm.
Yet, as soon as the RT does the STAT breathing treatment, the patient feels no better and the peek flow is the same before and after. Yet, three weeks later and after the insurance company is out $10,000 because of useless breathing treatments, the patient still has those treatments ordered.
And all of that because the doctor heard rhonchi and had no idea it was not a wheeze.
Rhonchi can also produce a bubbly sound over the throat and upper airway, which almost sounds like fluid is in there. You have the patient cough and usually this goes away. However, sometimes those secretions are further embedded in the upper airway, and this causes the COARSE sound you hear.
Sometimes these secretions are embedded by the vocal cords, and produce an audible sound. As I wrote in my last post, any lung sound that is audible is not a wheeze: it is rhonchi. Either that, or it is stridor.
Stridor is usually an audible inspiratory high-pitched sound. It is usually caused because of swelling near the vocal cords. It can be the result of croup or post extubation. It can be caused due to laryngospasms. And, despite contrary belief, it is a common lung sound in adults too. Only, it usually gets charted as a wheeze, so no one ever talks about it.
However, some RT books describe stridor as any noise inspiratory and expiratory that is heard in the throat. (Dana Oakes, "Clinical Practitioner's Pocket Guide to Respiratory Therapy," describes it this way).
To hear this noise, all you have to do is take your stethoscope and set it over the throat. If you hear it loud and clear their, then the noise you heard in the lower airways was this same sound.
Yet, it is true, many times doctors only listen to the posterior lungs and hear this high pitched sound and call it a wheeze, when it is actually upper airway stridor or rhonchi. A lot of older patients get secretions stuck right up behind the vocals, and they produce this high pitched sound. This happens sometimes for no reason on healthy adults, or it can happen on those with NGs, or simply OTL (Out To Lunch) patients or SGD (She's gonna die) patients.
I'm to the point now that I get so irritated when a doctor orders a treatment because a patient has upper airway swelling or secretions and no otherwise signs of shortness of breath, that if the doctor is still standing there, I will listen to the throat and say, "What you hear isn't a wheeze, it's stridor."
"Don't you know a wheeze by now," a doctor said to me once.
"Yes, and that's a stridor."
Of course I don't do that very often, only when I'm extremely busy and don't have time for such nonsensical treatments, very tired, or simply irritated. Unfortunately that doesn't happen enough around here, so our doctors continue to go uneducated.
Now I say doctors, I know there are some nurses and even a few RTs who have no clue what lung sounds are actually bronchospasm and which are secretions. I suppose this will be a continual battle.
However, there are some really smart doctors and RNs that I work with who know the difference, and don't call me every time they hear "COARSE" lung sounds.
Tomorrow I will expound a little about crackles and then maybe wheezes.
Tuesday, September 23, 2008
How to listen to lung sounds
As he places the stethoscope on your back, the doctor says, "Take a deep breath."
As an RT who has listened to the lung sounds of over 10,000 patients, I will tell you that having a patient take in a deep breath is not the ideal way to listen to lung sounds.
Ideally, you want the patient to breath normal. The reason is you want to hear what a patent's lungs sound like when he is breathing normal.
When a patient is taking in a deep breath, you will have more turbulence in the lungs, and you will hear a lot of extra noises, particularly upper airway noises, and secretions sitting in the throat. Throat noises are often mistaken for wheezes caused by bronchospasm.
So, here is an RT 101 coarse on how to listen to lung sounds. If I disagree with what you learned in RT, RN or DR school I apologize. But this is how you hear lung sounds.
First, you listen to the apices while the patient is breathing normal. Many times, though, the patient could have the worse lung sounds and still sound clear in the front, so this should never be the only place you listen.
Second, while the patient is still breathing normal, you'll want to listen to the right upper lobe and then left upper lobe, and then right lower lobe and left lower lobe. You do this because you want to make sure the lung sounds are equal on both sides.
If lung sounds are not equal, this may be indicative of whatever illness is ailing the patient. For example, crackles in one part of lung may be indicative of pneumonia. Diminished in one lobe may be indicative of pneumonia or pleural effusion or pneumo.
If a patient has fine crackles in the bases, you sometimes will not hear them unless the patient takes a deep breath. So, third, you have the patient take a deep breath while you listen to the bases for those fine crackles. This is how you hear your fine crackles.
Many times these crackles get missed by nurses, doctors and probably even some RTs. But never me.
Many times, if the crackles are equal in both bases, this may be a normal sound, particularly in COPD and CHF patients. However, fine crackles in the bases can be an early sign that the lungs are getting wet, and you should check the patients urinary output to see if he is retaining fluid.
See, by your proper lung assessment, you can easily prevent a patient from ever getting short-of-breath due to wet lung. And the Dr. and RN might even be impressed with you (or their faces might be red because they failed to listen at all).
Okay, by now you have heard all your lung sounds right? Wrong. When you listened you heard a loud wheeze throughout the lungfields. This "wheeze" may also even be audible.
Here is something I learned by experience and not through school: If the wheeze is audible it is not bronchospasm: it is a throat wheeze. Many times when a patient is wet he has a throat
wheeze, so when I hear this I assess for wet lungs while auscultating.
So, we have to add a fourth step that most doctors miss.
Fourth, listen to the patient's throat. If you hear the wheeze loud in the throat, there is a high likelihood that it is not a bronchospasm wheeze. It is probably a wheeze caused by phlegm in throat, or a dry throat, or snoring, or maybe even stridor.
Many times, doctors order breathing treatments just because a patient has throat wheezes that are RADIATING throughout the lungfields mimicking a bronchospasm wheeze. Many times this throat wheeze is laryngospasm, such as you might hear after a bronchoscopy or extubation.
If you follow these four simple steps you will always get accurate lung sounds. Then you go look at the chart to see what the doctor charted: "wheezes." Then the order says, "Albuterol Nebs Q4 ATC."
As a smart RT or smart RT student or smart RN you question the doctor: "What kind of wheezes? Where are the wheezes?"
You know that they are not bronchospasm wheezes, but the doctor doesn't. While you once thought a doctor could do no wrong, you now know better. You may even snicker.
As an RT who has listened to the lung sounds of over 10,000 patients, I will tell you that having a patient take in a deep breath is not the ideal way to listen to lung sounds.
Ideally, you want the patient to breath normal. The reason is you want to hear what a patent's lungs sound like when he is breathing normal.
When a patient is taking in a deep breath, you will have more turbulence in the lungs, and you will hear a lot of extra noises, particularly upper airway noises, and secretions sitting in the throat. Throat noises are often mistaken for wheezes caused by bronchospasm.
So, here is an RT 101 coarse on how to listen to lung sounds. If I disagree with what you learned in RT, RN or DR school I apologize. But this is how you hear lung sounds.
First, you listen to the apices while the patient is breathing normal. Many times, though, the patient could have the worse lung sounds and still sound clear in the front, so this should never be the only place you listen.
Second, while the patient is still breathing normal, you'll want to listen to the right upper lobe and then left upper lobe, and then right lower lobe and left lower lobe. You do this because you want to make sure the lung sounds are equal on both sides.
If lung sounds are not equal, this may be indicative of whatever illness is ailing the patient. For example, crackles in one part of lung may be indicative of pneumonia. Diminished in one lobe may be indicative of pneumonia or pleural effusion or pneumo.
If a patient has fine crackles in the bases, you sometimes will not hear them unless the patient takes a deep breath. So, third, you have the patient take a deep breath while you listen to the bases for those fine crackles. This is how you hear your fine crackles.
Many times these crackles get missed by nurses, doctors and probably even some RTs. But never me.
Many times, if the crackles are equal in both bases, this may be a normal sound, particularly in COPD and CHF patients. However, fine crackles in the bases can be an early sign that the lungs are getting wet, and you should check the patients urinary output to see if he is retaining fluid.
See, by your proper lung assessment, you can easily prevent a patient from ever getting short-of-breath due to wet lung. And the Dr. and RN might even be impressed with you (or their faces might be red because they failed to listen at all).
Okay, by now you have heard all your lung sounds right? Wrong. When you listened you heard a loud wheeze throughout the lungfields. This "wheeze" may also even be audible.
Here is something I learned by experience and not through school: If the wheeze is audible it is not bronchospasm: it is a throat wheeze. Many times when a patient is wet he has a throat
wheeze, so when I hear this I assess for wet lungs while auscultating.
So, we have to add a fourth step that most doctors miss.
Fourth, listen to the patient's throat. If you hear the wheeze loud in the throat, there is a high likelihood that it is not a bronchospasm wheeze. It is probably a wheeze caused by phlegm in throat, or a dry throat, or snoring, or maybe even stridor.
Many times, doctors order breathing treatments just because a patient has throat wheezes that are RADIATING throughout the lungfields mimicking a bronchospasm wheeze. Many times this throat wheeze is laryngospasm, such as you might hear after a bronchoscopy or extubation.
If you follow these four simple steps you will always get accurate lung sounds. Then you go look at the chart to see what the doctor charted: "wheezes." Then the order says, "Albuterol Nebs Q4 ATC."
As a smart RT or smart RT student or smart RN you question the doctor: "What kind of wheezes? Where are the wheezes?"
You know that they are not bronchospasm wheezes, but the doctor doesn't. While you once thought a doctor could do no wrong, you now know better. You may even snicker.
Thursday, July 31, 2008
An epidemic of Fake Pneumonia
It's spreading hospital to hospital, patient to patient, faster than any disease on the market. Would you believe the disease I'm referring to doesn't even exist. In fact, it's not even contagious.
I'm sure all nurses and RTs have seen it: it's fake pneumonia.
Fake pneumonia: Patients that are diagnosed with pneumonia, but there is nothing on the chart to indicate pneumonia. The x-ray and labs look normal. Auscultation reveals clear lung sounds. When the patient is asked, he or she indicates no trouble breathing. The patient says something like, "I've never been short of breath in my life."
(Click here to check the signs and tests that indicate real pneumonia)
So why the diagnosis of pneumonia. I can only make guesses here.
- The doctor had no clue what was wrong, so he chose the most common diagnosis
- Pneumonia is the most reimbursable diagnosis.
- The pt looked bad, but otherwise didn't meet criteria for admission.
- The doctor actually thought the patient had pneumonia.
- The patient is a lot of work for a family member, and they need a break
- There really is no reason.
And, in order to meet criteria for admission, all pneumonia patients must have Q4 breathing treatments ordered. If they are not sick enough to have breathing treatments, they are not sick enough to be admitted.
Fake pneumonia is very contagious. You cannot get it by person to person contact. You can only get it from your doctor. So be wary.
That is, unless you want to be admitted. If that's the case, see a participating* doctor near you.
*Note: Not all doctors in your area will paritcipate in this program.
Sunday, July 6, 2008
SOB is not always caused by bronchospasm
So long as there are doctors who think that a bronchodilator treatment will cure everything that causes shortness-of-breath, there will always be frustrated RTs.
As long as their are doctors who believe that all adventitious lung sounds are an indication for a bronchodilator, there will be frustrated RTs.
Let's make this simple, and get right to our next RT Cave Rule:
As long as their are doctors who believe that all adventitious lung sounds are an indication for a bronchodilator, there will be frustrated RTs.
Let's make this simple, and get right to our next RT Cave Rule:
RT Cave Rule #22: Everything that cause shortness-of-breath does not get fixed with a bronchodilator. Bronchodilators relax the smooth muscles of the bronchioles, and thus treat bronchospasm only.
RT Cave Rule #23: All adventitious lung sounds are not an indication for a bronchodilator.
That in mind, I have a few case studies here. I would like you to answer three questions for each case study: 1) What is your initial impression of the patient, or what do you think is wrong? 2) Would you recommend a bronchodilator and why? If yes, what frequency? 3) What do you think the doctor actually ordered?
I'll put the answers below, don't peek.
#1: You are doing an EKG on a patient who says he is mild SOB, but feels much better once he is on 2lpm nasal cannula. You notice he has the cardiac scar. After you finish the treatment, you learn by auscultation he has crackles 1/2 way up.
#2: You are doing an EKG, and you ask the patient if he is having any shortness-of-breath or chest pain. He says, "No. I'm having bad back pain." Upon auscultation you learn the patient has crackles in the left lower lobe. He then reveals that he does have pain with deep inspiration.
#3: You are called STAT to ER for a patient in severe respiratory distress. He has been a 3 pack a day smoker since he was 7, and he's 77. His ABGs are cruddy, and reveal severe acidosis. You look up on the monitor and see the prototypical fireman's helmet on the rhythm strip. This is verified by an EKG.
#4: You have a patient who has asthma and he smokes. He states that he is mild sob.
Here is how the above cases turned out:
#1: The patient has obvious signs of CHF. No breathing treatment indicated. If the patient is wet, you don't want to put more fluid into his lungs. The patient should be treated for suspected CHF, with some Lasix perhaps. Along with diagnosing and treating the CHF, the doctor ordered Q1 hour bronchodilator.
#2: I surmised the patient had pneumonia of the left lower lobe. I would recommend no breathing treatment because the patient is not SOB and shows no signs of bronchospasm. The doctor diagnosed the patient with pleurisy. She diagnosed this way because "the x-ray showed no pneumonia, and his labs are normal." Still, I think this guy has pneumonia, but that's just my humble guess. Either way, a bronchodilator doesn't treat inflammation. Still, a Q1 hour bronchodilator was ordered. The patient noted no difference with any of them.
#3: The pt is labored secondary to having an MI. The patient needs to be intubated. The doctor eventually intubated the patient, but only after an hour long continuous bronchodilator treatment was finished with no results.
#4: This patient has a good chance of bronchospasm. A bronchodilator is indicated because bronchodilators treat bronchospasm. The patient was diagnosed with asthma attack. The treatment really opened the patient up, and a second one was probably warranted. The doctor ordered a one time breathing treatment. A second treatment was never ordered on this patient who actually could have benefited from a second one.
So, how did you do. I bet you did pretty well.
Personally, I think it is fine to try a bronchodilator on all these patients, because there's always a possibility there might be a bronchospasm component. The ordering of further treatments should be based on assessment.
But that's just me.
Tuesday, July 1, 2008
You cannot schedule SOB time
It is a firm belief of mine that if a patient isn't having constant problems with bronchospasm, like an asthmatic or COPD patient, then Albuterol b10reathing treatments should never be ordered QID.
The reason I say this, is that bronchodilators should, technically speaking, only be given when a patient is having trouble breathing secondary to bronchospasm, and the only way you can tell if this is occurring is to be in the room assessing the patient.
In other words, it is not possible to know in advance when a patient will be short of breath. You cannot schedule SOB time. Therefore, Dr. should use all the recourse's that are available to them, which are their respiratory therapists. RTs can go into the room at scheduled times to assess the patient to determine if the treatment is needed.
This is why I am such a proponent of protocols. Or, at the least, I think all treatments should be ordered every four hours as needed (Q4prn) . We go into the room, assess the patient, and give the treatment only if there are signs of bronchospasm.
Thus, here is RT Cave Rule #20:
And this brings us to RT Cave Rule #21:
The reason I say this, is that bronchodilators should, technically speaking, only be given when a patient is having trouble breathing secondary to bronchospasm, and the only way you can tell if this is occurring is to be in the room assessing the patient.
In other words, it is not possible to know in advance when a patient will be short of breath. You cannot schedule SOB time. Therefore, Dr. should use all the recourse's that are available to them, which are their respiratory therapists. RTs can go into the room at scheduled times to assess the patient to determine if the treatment is needed.
This is why I am such a proponent of protocols. Or, at the least, I think all treatments should be ordered every four hours as needed (Q4prn) . We go into the room, assess the patient, and give the treatment only if there are signs of bronchospasm.
Thus, here is RT Cave Rule #20:
Why force your RT to wake a patient up in the middle of the night to give a treatment that is not indicated. Use your RT, have him assess the patient every four hours if you think that is necessary, and determine if a breathing treatment is really indicated.RT Cave Rule #20: You cannot schedule SOB time. You cannot know in advance that a patient will be short of breath every four hours. Therefore, unless the patient is chronically SOB due to asthma or COPD, treatments should not be ordered Q4, they should be ordered Q4 prn.
And this brings us to RT Cave Rule #21:
That concludes today's class.RT Cave Rule #21: You cannot know in advance when a patient is going to be SOB, and SOB due to bronchospasm is the only indication for a bronchodilator.
Sunday, June 22, 2008
A guideline is just a guideline
The Happy Hospitalist wrote a neat post about guidelines from a doctor's perspective. But he reminds us that while a guideline is a good tool, it is just a guideline.We'll make this RT Cave Rule #15:
RT Cave Rule #15: A guideline is just a guideline. It is not a substitute for experience and common sense. For the most part, that guideline is just a tool.
I've written on this blog about how sometimes asthmatics require a bronchodilator more often than is recommended on guidelines.com. Sure the guideline states that if a rescue inhaler is needed more than 2-3 times a week, your asthma is not controlled. But just because someone uses his inhaler more often, does not always make for uncontrolled asthma.
Look at it this way. What if a person had bad asthma, and used his inhaler 10 or more times in a day. As time goes by he and his doctor eventually find a better medicine routine, and the patient makes a few changes in his life, that allows him to only need to use his MDI 2-3 times a day instead of 10.
This same person is active in the community, and stays physically active. You cannot tell me that this person has uncontrolled asthma.
In fact, this brings us to RT Cave Rule #16:
RT Cave Rule #16: If you have asthma and you do not miss work, and you do not miss school when you are a kid, and you are able to lead a relatively normal life, then your asthma is controlled. That's how we define asthma control. It's not based on how often you use your rescue inhaler.
The same is true of COPD:
RT Cave Rule #17: Whether someone has controlled COPD is not based on how many times a rescue inhaler is used, or how much oxygen the patient is on, but whether or not that patient can continue to be a productive member of society.
Ideally, however, you want your asthma and COPD patients to not need to use their rescue inhalers, but in the real world, many lung patients get short-of-breath when they wake up in the morning, and might need a few puffs. I don't see a problem with that.
I can use myself as an example here. I have asthma. I work out just about every day, and I jog (not walk) four times a week. And I rarely use my inhaler during the day. However, I do use it a few times during the night, most particularly first thing in the morning. And, most important, I have never missed one day of work due to my asthma. I'd consider my life as normal; my asthma stops me from doing nothing.
However, I have had a few people email me and tell me my asthma is not controlled because the asthma guidelines state that if you use your MDI more than twice a week, then your asthma is not controlled. That might be true of most asthmatics, but there are exceptions to every rule that doctors have to be prepared for.
The same can be said of COPD patients. If you measured COPD control based on how often a rescue inhaler is used, then there would be very few COPD patients who have control of their illness. As we learn in RT school, the goal with COPD patients is to help them remain productive members of society.
Sure, Mrs. Beady might need to use oxygen 24 hours a day, and may even go through an inhaler every month, but her disease does not stop her from performing the daily routines she has been doing her entire life. She is a productive member of society.
Another example of how guidelines are sometimes misused is with ACLS. We have some doctors here who go by ACLS as though it were the Bible.
The other day, for example, I was bagging this little-old-lady with one hand while holding the mask with the other. There was no problem. Air was going in easy.
Then Dr. Krane decided to hold the mask with her two large hands, and I let go and used two hands to bag the same tidal volume. Air started squirting out the edges of the mask: BLLLLLLLLPPPPPPPP.
I looked through the mask, and saw that poor little old ladies facial features all squeezed together. Air wasn't getting in.
"I think you better ease up a bit," I said.
She said, "ACLS recommends one person hold the mask, and one person bag." Yeah, but this lady was ventilating just fine until you grabbed the mask. Let go!
She did not. She had to live up to those ACLS guidelines to a tee, even if it was to the detriment to the patient. The patients sats dropped suddenly.
Now I was in a predicament, because I certainly didn't want to overrule a doctor when she was standing right next to me. Finally, she let go to grab the ETT, and I pumped in some nice easy breaths real fast, and our patient pinked up just fine.
Our doctors are also particular to doing three Q20 minutes treatments. Or, in Dr. Krane's case, Q1 hour treatments. One day I asked Dr. Krane why she does that, she said, "Because it's in the asthma guidelines."
That's fine and dandy, I thought. But what if that first treatment worked and a second wasn't needed. Do I still need to give a second treatment when that first one worked just fine? The patient's all shaky and jittery from the first, do we have to give a second?
According to her guidelines the answer is yes. According to my RT Cave rule, common sense says no.
This brings me to another RT cave rule #18:
RT Cave #18: While guidelines should always be considered, each patient and each patient situation should be assessed and treated individually. We cannot treat all patients the same, as most guidelines portray.
It all comes down to common sense. Guidelines are only as good as the paper they are written on. While they can be a great tool, common sense is the key.
Thursday, June 12, 2008
The hypoxic drive theory: debunked
(This is part four of a six post series. To go to part one click here.)
All my fellow RTs have whitnessed it: the CO2 retainer who is breathing normal, is not in respiratory distress, has his oxygen turned up, and nothing bad happens. The patient does not stop breathing. Why is that?
It is because the hypoxic drive theory is not true. If it were, we'd have many more COPD patients dying each day.
What is really going on?1
The hypoixic drive is real, but it is not what causes CO2 to rise. There are essentially two different reasons why CO2 might rise in COPD retainers.
Reason #1: V/Q mismatching. Allow me to quote Jeff Whitnack from over at Jeff Whitnack's RT Page (actually, I believe he is paraphrasing a chapter by Robert Lodato in Martin Tobin's book, "Principles and Practices of Mechanical Ventilation," (pages838-9):
If we simply clung to the hypoxic drive theory, and didn't give these patients the oxygen they need to maintain a healthy heart and brain, they are more likely to die than if we given them oxygen.
Reason #2: The Haldane Effect:
All my fellow RTs have whitnessed it: the CO2 retainer who is breathing normal, is not in respiratory distress, has his oxygen turned up, and nothing bad happens. The patient does not stop breathing. Why is that?
It is because the hypoxic drive theory is not true. If it were, we'd have many more COPD patients dying each day.
What is really going on?1
The hypoixic drive is real, but it is not what causes CO2 to rise. There are essentially two different reasons why CO2 might rise in COPD retainers.
Reason #1: V/Q mismatching. Allow me to quote Jeff Whitnack from over at Jeff Whitnack's RT Page (actually, I believe he is paraphrasing a chapter by Robert Lodato in Martin Tobin's book, "Principles and Practices of Mechanical Ventilation," (pages838-9):
Imagine the worst ventilated alveoli. The local CO2 pressure there may be 100 or more. On room air the local O2 pressure will surely be less than 60 torr. At this level of local hypoxemia, the adjacent pulmonary vasculature will constrict. Blood will then be sent to the alveoli which is ventilating more effectively. Ventilation/ perfusion matching is enhanced. But if 100% O2 is given the O2 pressure will not drop below 60, the pulmonary vasculature will not constrict, and V/Q matching will not be optimized. Just as giving Nipride may drop the PaO2 as hypoxic pulmonary vasoconstriction is released, so giving 100% O2 may also raise the PaCO2. This also can happen to patients in an asthmatic crisis given 100% O2. It’s not that we knock out a hypoxic drive, so much as we drive in a hypercarbic potential. Then further compromise ventilation through increased V/Q mismatching.For the patients I described at the top of this post, it is this -- V/Q mismatching -- that is causing the patient's CO2 to be high, and therefore it is actually safe to have this patient on 100% FiO2 without causing that patient to become lethargic or to die.
If we simply clung to the hypoxic drive theory, and didn't give these patients the oxygen they need to maintain a healthy heart and brain, they are more likely to die than if we given them oxygen.
Reason #2: The Haldane Effect:
Unsaturated hemoglobin carries CO2. A patient in crisis may arrive in the ER with an SpO2 on room air of 75%, the unmeasured mixed venous saturation may then in turn also be much lower than the 75% norm. All this unsaturated hemoglobin is then carrying an extra CO2 load. This is in the setting whereby the patient has an already elevated PaCO2, perhaps has an elevated Hgb (hemoglobin) after years of hypoxemia, and is “topped off” on their ability to ventilate. So for every rise in their SpO2 we are driving more CO2 into the plasma. If this were you or I, we would simply then ventilate this extra CO2 out via the lungs. But their lungs can’t and don’t, therefore the CO2 shows up in the “downstream” ABG.
This is why you will see a rising CO2 in many CO2 patients when they are placed on increased amounts of oxygen, and they can still talk to you. They are in no respiratory distress, yet the doctor is thinking, "Turn down the oxygen."
If the Haldane effect is causing a person's CO2 to be high, then we need to be on the lookout for impending respiratory failure, and have our BiPAP or ETT ready.
If a patient is on 100% Fio2 you should be concerned that the CO2 might go up, especially if his sat of 100%. What you should do here is back off on the oxygen until you have an SpO2 of 92%, which is where most of our doctors like to keep that sat per our oxygen protocol on non COPD patients.
So why do we make COPD patients suffer with a sat of 88%? It's because most of our doctors believe in the hypoxic drive theory.
Usually the patient will only become lethargic with excessive O2 therapy when he is already compromised, he is pooped out (fatigued), and he cannot blow off the excess CO2 because he has no more pulmonary capacity of which to increase his minute ventilation. It is these patients whose CO2 increases to greater than 90, and of whom are prone to pass out due to too high of a CO2.
And we have all seen this happen. It's about 30% of COPD patients.
So keep an eye on them. Have your airway box ready. But don't make them suffer with an SpO2 in the low 80s just because of the hypoxic drive theory.
Many times we have a patient on the vent and have to get them down to 88% SpO2 because "that's what they live with at home on 2lpm." So, why not send them home on 4lpm with an SpO2 of 92%? This is exactly what is recommended on this slide (source unknown):
- Give oxygen, maintain SpO2 >92%
- Close observation for changes in mental status
- Use of non-invasive CO2 monitoring
- Early use of non-invasive ventilation if needed
At least we could try them on 4lpm and do an ABG an hour or so later. If the CO2 doesn't go up and you have the PO2 you want, then by golly send the patient home on 4lpm. Likewise, if the CO2 does go up slightly, and the patient is still talking to you, then by golly send the patient home on 4lpm.
But you know what? We never do this study on patients. I've never done it once in my 10 year career as an RT. Why? Because doctors don't need to do this oxygen study, because they have already bought into the hypoxic drive theory.
But, as Whitnack writes, "if that same patient is at home and resting while watching the ball game on TV as their O2 accidentally gets turned up by 1 l/m -- well, they won't stop breathing and that's why I've never met an ambulance with such a patient on board."
Great point I say.
Consider this example he gives. I've seen it, and so have you more than likely:
Picture the COPDer whom arrives in the ER SOB with a RR 45 and initial PaO2 44, PaCO2 66, pH 7.35 on RA. So someone places them on 8 l/m simle mask and draws another ABG-- now they are PaO2 110, PaCO2 80, pH 7.25. The patient's RR is now 26 and the patient's respiratory effort is much less labored. Did we knock out that patient's drive to breathe? Or did we relieve the patient's hypoxemia sufficient that the patient could practice their own form of permissive hypercapnea? If we intubated the patient and considered his auto-peep, we may be happy with the latter ABGs also.
Which is also a reason why we should never panic and rush to intubate someone.
Why is it that we never hear about the COPD patient dying who is stable in his room, but accidentally has his oxygen increased from 2lpm to 5lpm? If the hypoxic drive were true, shouldn't that patient become lethargic, and maybe even go into cardiopulmonary arrest.
Instead, he's in his room watching the Detroit Tigers and munching on gram crackers.
Now we know why.
Click here for a neat slideshow regarding the hypoxic drive myth. Rather, it's now called Oxygen Induced Hypercapnia, not hypoxic drive.
(To view part five click here. To return to part one click here.)
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